1. Carcinoma of the female breast.(Incidence, Etiology and pathology)

Question 1

INCIDENCE of Carcinoma of female breast

Answer 1

• It is the commonest malignancy in female.

* In USA, 1 in every 9 women is expected to develop cancer breast in lifetime

Question 2

Etiological factors of Carcinoma of female breast

Answer 2

1. Genetic element
2. High (Major) Risk Factors
3. Intermediate Risk Factors

Question 3

Genetic element of etiological factors of Carcinoma of female breast

Answer 3

Genetic element: mutation of the following tumour suppressor genes:

• BRCA 1 located on chromosome No.17
• BRCA 2 located on chromosome No.13
• TP53 (p53) located on chromosome No.17

Question 4

Le Fromaini syndrome

Answer 4

(Mutation of p53 tumour suppressor gene) :

• colorectal cancer
• endometrial cancer
• cancer breast

Question 5

High (Major) Risk Factors of breast cancer

Answer 5

1. Female with cancer of one breast.
2. Female with near relatives having history of cancer breast.
3. Nulliparous female
4. Fibroadenosis with papillomatosis.
5. Atypical ductal hyperplasia.
6. Duct papilloma
7. Lobular carcinoma in situ

Question 6

lntermediate Risk Factors of breast cancer

Answer 6

1. It has a peak incidence at 45 - 55 y, 65 - 75 y.
2. Females with early menarche .12 y or late menopause > 50 y.
3. Infertility & delayed pregnancy.
4. Prolonged use of contraceptive pills > 10 years.
5. Obesity & White races.
6. High socio-economic class.
7. Artifrcial breast prosthesis.
8. Smoking, coffee, red meat & high fat diet.
9. Irradiations.

Question 7

Pathology of breast cancer

Answer 7

Site

Types

Question 8

Site in Pathology of breast cancer

Answer 8

Mostly affecting the upper outer quadrant (60%).

Question 9

Types in Pathology of breast cancer

Answer 9

According to the cell of origin :

I- Ductal carcinoma. (80-85%)
Il- Lobular carcinoma. (10-15%)
III- Paget’s disease of the nipple. (1%)
IV- Rare types of carcinoma.(Mastitis carcinomatosa)

Question 10

Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 10

1. Non-lnvasive Ductal Carcinoma (Ductal Carcinoma in situ)

2. lnvasive Ductal Carcinoma

Question 11

Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 11

1. Low and intermediate grade DCIS:

2. High grade DCIS:

Question 12

Pathogenesis of Low and intermediate grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 12

1. Papillary & micropapillary DCIS
2. Solid DCIS
3. Cribriform DCIS

Question 13

Pathogenesis of High grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 13

Comedo DCIS

Question 14

Papillary & micropapillary DCIS in Pathogenesis of Low and intermediate grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 14

1. Microscopic picture:

2. Clinical picture

Question 15

Microscopic picture of Papillary & micropapillary DCIS in Pathogenesis of Low and intermediate grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 15

The cancer cells are arranged in a finger-like pattern within the duct

If the cells are very small, they are called micropapillary.

Question 16

Clinical picture of Papillary & micropapillary DCIS in Pathogenesis of Low and intermediate grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 16

Leads to bleeding per nipple.

Question 17

Microscopic picture of Solid DCIS in Pathogenesis of Low and intermediate grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 17

The tumor cells completely fill the involved ducts.

Question 18

Microscopic picture of Cribriform DCIS in Pathogenesis of Low and intermediate grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 18

1. There are gaps between cancer cells in the affected breast ducts
2. like the pattern of holes in Swiss cheese.

Question 19

Comedo DCIS in Pathogenesis of High grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 19

1. Microscopic picture

2. Pathogenesis of Comedo necrosis

Question 20

Microscopic picture of Comedo DCIS in Pathogenesis of High grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 20

The center of the breast duct is plugged with dead cancer cells scattered among the living ones.

Question 21

Pathogenesis of Comedo necrosis in Comedo DCIS in Pathogenesis of High grade DCIS in Pathogenesis of Non-lnvasive Ductal Carcinoma (DCIS) in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 21

Necrosis in malignancy usually means that the cancer is growing fast & some cells don’t get enough nourishment, these starved cells die off, leaving areas of necrosis.

Question 22

Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 22

1- lnvasive duct carcinoma not otherwise specified “NOS” > 75 %

2- Medullary carcinoma: 5%

3- Mucinous carcinoma 1%

Question 23

Pathogenesis of NOS in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 23

1. Alternative names for NOS
2. Gross picture
3. Cut section
4. Microscopic picture

Question 24

Alternative names for NOS in Pathogenesis of NOS in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 24

NSP no special type

scirrhous carcinoma

Question 25

meaning of scirrhous carcinoma

Answer 25

Means alot of fibrous tissue

Question 26

Gross picture in Pathogenesis of NOS in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 26

* Small, hard, irregular mass * with flat under-surface * fixed within the breast.

Question 27

Cut section in Pathogenesis of NOS in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 27

1- Gritty. 2- Retract (concave) due to the fibrous tissue inside. 3- Non-capsulated. 4- Pale grayish with yellowish white streaks 5- areas of hemorrhage & necrosis.

Question 28

Meaning of Gritty

Answer 28

Full of fibrous tissue Akennak bte2ta3 fe kommetra

Question 29

why some cut sections are concave others are convex ?

Answer 29

Concave : much fibrous tissue Convex : little fibrous tissue

Question 30

Microscopic picture in Pathogenesis of NOS in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 30

1- Masses of small malignant spheroidal cells 2- arranged in irregular groups 3- separated by dense fibrous tissue 4- with areas of hemorrhage & necrosis. 5- The fibrous tissue element is more than the cellular element.

Question 31

Pathogenesis of Medullary carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 31

1. Alternative name for Medullary carcinoma 2. Gross picture 3. Cut section 4. Microscopic picture 5. Aggressiveness and prognosis

Question 32

Alternative name for Medullary carcinoma in Pathogenesis of Medullary carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 32

encephaloid carcinoma

Question 33

Gross picture in Pathogenesis of Medullary carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 33

Large, irregular mass & soft in consistency.

Question 34

Cut section in Pathogenesis of Medullary carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 34

1. Bulge (convex) 2. Non-capsulated 3. brain like appearance. 4. areas of hemorrhage and central necrosis.

Question 35

Microscopic picture in Pathogenesis of Medullary carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 35

1- Large masses of malignant spheroidal cells 2- arranged in pseudoacinus form. 2- The stroma is scanty and the vascularity is high. 3- cellular element > fibrous tissue element 4- Lymphocytic infiltration may be present.

Question 36

Tumours with Lymphocytic infiltration:

Answer 36

1) seminoma 2) Medullary breast carcinoma 3) monomorphic adenoma of parotid

Question 37

Aggressiveness and prognosis in Pathogenesis of Medullary carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 37

It's less aggressive and metastasize later and hence has better prognosis than NOS

Question 38

Pathogenesis of Mucinous carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 38

1. Alternative name for Mucinous carcinoma 2. Gross picture 3. Cut section 4. Microscopic picture 5. Prognosis

Question 39

Alternative name for Mucinous carcinoma in Pathogenesis of Mucinous carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 39

colloid carcinoma

Question 40

Gross picture in Pathogenesis of Mucinous carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 40

Large cystic tumour

Question 41

Cut section in Pathogenesis of Mucinous carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 41

Honey comb appearance due to colloid

Question 42

Microscopic picture in Pathogenesis of Mucinous carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 42

Malignant cells producing abundant mucin giving the signet ring appearance.

Question 43

meaning of signet ring appearance.

Answer 43

Nucleus is pushed to side by mucin

Question 44

Prognosis in Pathogenesis of Mucinous carcinoma in Pathogenesis of lnvasive Ductal Carcinoma in Pathogenesis of Ductal carcinoma in Types in Pathology of breast cancer

Answer 44

Unlike colloid carcinoma of GIT, it has usually a good prognosis

Question 45

Lobular carcinoma in Types in Pathology of breast cancer

Answer 45

1. Cell of origin 2. Behavior 2. Pathogenesis

Question 46

Cell of origin of Lobular carcinoma in Types in Pathology of breast cancer

Answer 46

Terminal lobular ducts or the acini.

Question 47

Behavior of Lobular carcinoma in Types in Pathology of breast cancer

Answer 47

It's bilateral and mulitcentric

Question 48

what is bad about lobular carcinoma

Answer 48

It's bilateral and mulitcentric so conservative breast surgery is contraindicated

Question 49

Pathogenesis of Lobular carcinoma in Types in Pathology of breast cancer

Answer 49

1. Non-invasive lobular carcinoma (LCIS) | 2. Invasive lobular carcinoma

Question 50

Pathogenesis of Non-invasive lobular carcinoma (LCIS) in Pathogenesis of Lobular carcinoma in Types in Pathology of breast cancer

Answer 50

1. Gross picture 2. Microscopic picture 3. Prognosis

Question 51

Gross picture in Pathogenesis of Non-invasive lobular carcinoma (LCIS) in Pathogenesis of Lobular carcinoma in Types in Pathology of breast cancer

Answer 51

Common to be an incidental finding associated with a breast biopsy performed for another indication.

Question 52

Microscopic picture in Pathogenesis of Non-invasive lobular carcinoma (LCIS) in Pathogenesis of Lobular carcinoma in Types in Pathology of breast cancer

Answer 52

1. A monomorphic population of small, rounded, Loosely cohesive cells 2. Fill and expand the acini of a lobule.

Question 53

Prognosis in Pathogenesis of Non-invasive lobular carcinoma (LCIS) in Pathogenesis of Lobular carcinoma in Types in Pathology of breast cancer

Answer 53

* Approximately, 10-20% of women with LCIS develop invasive breast cancer within 15 years from their LCIS diagnosis. * Thus, LCIS is considered a biomarker of increased breast cancer risk

Question 54

The reason why LCIS is considered a biomarker of increased breast cancer risk

Answer 54

Approximately, 10-20% of women with LCIS develop invasive breast cancer within 15 years from their LCIS diagnosis.

Question 55

Invasive lobular carcinoma in Pathogenesis of Lobular carcinoma in Types in Pathology of breast cancer

Answer 55

Consists of cells morphologically identical to LCIS but with invasion of the basement membrane. Occasionally they surround normal-appearing acini or ducts

Question 56

Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 56

1. Definition 2. Spread 3. Microscopic picture 4. Clinical picture 5. Differential Diagnosis

Question 57

Definition of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 57

lt is a slowly growing intraductal carcinoma that begins in the epithelium of a main collecting lactiferous duct

Question 58

Spread of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 58

1. Outward | 2. Inward

Question 59

Outward Spread of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 59

* affecting the skin of the nipple & areola | * leading to superficial erosions, ulcerations & crustations.

Question 60

Inward Spread of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 60

Later on it spreads inwards & a mass appears 2 years from the onset of the disease

Question 61

Microscopic picture of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 61

1. Epidermal hyperplasia & hyperkeratosis. 2. Malignant Paget's cells in all layers of the epidermis 3. The dermis contains a dense infiltrate of lymphocytes, histiocytes, plasma cells, and occasionally eosinophils.

Question 62

Morphology of Malignant Paget's cells in Microscopic picture of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 62

Large, oval or rounded cells with intracytoplasmic vacuoles & large hyperchromatic nuclei with prominent nucleoli "high nuclear-to-cytoplasmic"

Question 63

Clinical picture of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 63

Usually occurs at menopause [6th decade] Pricking sensation of the nipple with erosions & ulcerations

Question 64

Differential Diagnosis of Paget's disease (CIS) in Types in Pathology of breast cancer

Answer 64

Eczema

Question 65

differentiate between Paget's disease and Eczema by

Answer 65

1. side 2. age 3. itchiness 4. Presence of vesicles-oozing 5. Edge 6. Biopsy 7. Response to treatment

Question 66

side of Paget's disease

Answer 66

Unilateral

Question 67

side of Eczema

Answer 67

Commonly Bilateral

Question 68

age in Paget's disease

Answer 68

Usually occurs at menopause [6th decade]

Question 69

age in Eczema

Answer 69

Commonly occurs at lactation

Question 70

itchiness of Paget's disease

Answer 70

May be itchy

Question 71

itchiness of Eczema

Answer 71

always itchy

Question 72

Presence of vesicles-oozing in Paget's disease

Answer 72

No vesicles no oozing (dry)

Question 73

Presence of vesicles-oozing in Eczema

Answer 73

vesicles are present - oozing

Question 74

Edge of Paget's disease

Answer 74

Well defined.

Question 75

Edge of Eczema

Answer 75

Ill defined

Question 76

Biopsy in Paget's disease

Answer 76

Biopsy is diagnostic

Question 77

Biopsy in Eczema

Answer 77

Biopsy is diagnostic

Question 78

Response to treatment in Paget's disease

Answer 78

no response to eczema treatment

Question 79

Response to treatment in Eczema

Answer 79

responds to eczema treatment

Question 80

Mastitis carcinomatosa in Types in Pathology of breast cancer

Answer 80

1. Alternative name for Mastitis carcinomatosa 2. Clinical picture 3. Behavior 4. Prognosis 5. Differential Diagnosis

Question 81

Alternative name for Mastitis carcinomatosa in Types in Pathology of breast cancer

Answer 81

Acute inflammatory (Lactating) carcinoma

Question 82

Clinical picture of Mastitis carcinomatosa in Types in Pathology of breast cancer

Answer 82

* Occurs mostly during pregnancy and lactation (due to high hormonal level) * but may occur at any age unassociated with these events. * The overlying skin is red, warm & edematous.

Question 83

Behavior of Mastitis carcinomatosa in Types in Pathology of breast cancer

Answer 83

* Aggressive rapidly metastasizing tumour * Considered stage lV cancer breast. * The tumour infiltrates the breast diffusely & the overlying skin is red, warm & edematous.

Question 84

Prognosis of Mastitis carcinomatosa in Types in Pathology of breast cancer

Answer 84

A Very bad prognosis. The patient dies within few months.

Question 85

Differential Diagnosis of Mastitis carcinomatosa in Types in Pathology of breast cancer

Answer 85

Acute bacterial mastitis.

Question 86

Differentiate between Mastitis carcinomatosa and acute bacterial mastitis by

Answer 86

1. onset 2. Fever 3. Degree of breast involvement 4. Axillary nodes 5. CBC 6. Response to antibiotics

Question 87

onset of Mastitis carcinomatosa

Answer 87

Gradual onset

Question 88

onset of acute bacterial mastitis

Answer 88

Acute onset

Question 89

Fever in Mastitis carcinomatosa

Answer 89

no or low grade fever

Question 90

Fever in acute bacterial mastitis

Answer 90

high fever

Question 91

Degree of breast involvement in Mastitis carcinomatosa

Answer 91

involves more than one third of the breast

Question 92

Degree of breast involvement in acute bacterial mastitis

Answer 92

one breast sector is affected

Question 93

Axillary nodes in Mastitis carcinomatosa

Answer 93

non tender axillary nodes (hard fixed)

Question 94

Axillary nodes in acute bacterial mastitis

Answer 94

tender axillary nodes

Question 95

CBC in Mastitis carcinomatosa

Answer 95

NAD

Question 96

CBC in acute bacterial mastitis

Answer 96

Leucocytosis

Question 97

Response to antibiotics in Mastitis carcinomatosa

Answer 97

no response to antibiotics in one week is an indication for biopsy

Question 98

Response to antibiotics in acute bacterial mastitis

Answer 98

The lesion is either cured by antibiotics or forms an abscess

Question 99

Histological grading of breast cancer

Answer 99

1. Mechanism | 2. Grades

Question 100

Mechanism of Histological grading of breast cancer

Answer 100

This grading is done according to a numerical grading system based on scoring of 3 individual factors: * Mitotic rate * Nuclear pleomorphism * Tubular formation

Question 101

Grades of Histological grading of breast cancer

Answer 101

All pathological types are classified according to the degree of differentiation to: Grade l : Well differentiated . Grade ll : Moderately differentiated. Grade lll : Poorly differentiated.

Question 102

Recent pathological classification of breast cancer

Answer 102

A) Non-invasive carcinoma B) Invasive carcinoma

Question 103

Non-invasive carcinoma according to Recent pathological classification of breast cancer

Answer 103

1. Ductal carcinoma in situ. 2. Lobular carcinoma in situ. 3. Paget's disease of the nipple (with no mass). 4. Non invasive papillary carcinoma.

Question 104

Invasive carcinoma according to Recent pathological classification of breast cancer

Answer 104

1. Invasive ductal carcinoma not otherwise specified "NOS". 2. Invasive lobular carcinoma. 3. Medullary carcinoma. 4. Mucinous (colloid carcinoma). 5. Inflammatory carcinoma. 6. Paget's disease with a mass. 7. Tubular carcinoma. 8. Papillary carcinoma. 9. Adenoid cystic (cribriform) carcinoma. 10. Metaplastic breast cancer (MBC). 11. Carcinoma with neuroendocrine differentiation.

Question 105

DCIS Leads to bleeding per nipple.

Answer 105

Papillary & micropapillary DCIS